Introduction:
breast cancer patients are presenting at advanced stages for oncological treatment in Nigeria and World Health Organization predicted developing countries incidence and mortality to increase by year 2020.

Methods:
prospective observational hospital based study that enrolled breast cancer patients from catchment area of an oncology service hospital in Nigeria between 2007 and 2013. Patientsí demographics, breast cancer burden and care giver presentation variables were analysed for causal factors of seeking medical help and what determines commencement of effective oncological treatment.

Conclusion:
patientsí bio-characteristics that determine their choice of health care provider should be incorporated into community breast cancer sensitization drives. Additionally, there is a need for a government agency assign the task of accrediting and defining scope of enterprise of health care institutions and their care providers in our pluralist health system.

Introduction

Breast cancer is the commonest cancer among women worldwide and the
most common cause of cancer related morbidity and mortality [1-3].
There is marked geographical variation in morbidity and mortality of breast
cancer between the developed and developing countries [4-7].
Breast cancer screening and early presentation has changed the dismal outcome
of this disease in the developed countries where despite increasing incidence,
the morbidity and mortality are declining [4, 8].
However, the contrary is true in developing countries especially Nigeria where
despite alarming increase in incidence, about 70 - 80% of breast cancer
patients are still presenting with locally advanced or metastatic breast
cancer [9-12]. More worrisome is the World Health Organization
(WHO) report that expects world breast cancer incidence and mortality to
increase by 50% by 2020 and this increase is anticipated to be highest in
the developing countries of which Nigeria is inclusive: where 55% increase
in incidence and 58% increase in mortality is predicted [13, 14].
In preparing for this anticipated increase, priority in developing countries
should be to formulate breast cancer control strategies such as early breast
cancer detection and early presentation for effective oncological treatment
[15, 16] .
The objective of this study is to find out patientsí related factors promoting
early presentation and causal factor(s) of effective oncological treatment with
the aim of reducing breast cancer related morbidity and mortality.

Methods

This is a cross-sectional hospital based study carried out at Wesley Guild Hospital (WGH) in Ilesa, between January 2007 and December 2013. Ilesa is a cosmopolitan town situated in Osun States in south western Nigeria. The town has good roads network connection and transport system, it health system is pluralist made up of orthodox and modern health facilities and the modern health facilities consist of private and government owned hospitals. WGH is one of the governments owned hospital and is a satellite hospital of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria.
Eligibility for the study is being a breast cancer patient presenting at the surgical oncology unit of WGH consenting to recruitment and data collected to be used for research purpose.
Inclusion criteria were: being domicile in Ilesha and malignant breast lesion. Exclusion criteria were: being domicile outside Ilesha, benign breast lesion and inability to provide adequate information because of karnofsky performance status.
Data obtained were patientsí demographics, clinical and laboratory details of breast cancer burden using American Joint Committee on Cancer (AJCC) staging system and evolution of patientís presentation to health care provider(s).
Patients were subdivided into two groups whether they presenting primarily or secondarily for oncological treatment
Data obtained were entered into the proforma designed for the study and analysed using Statistical Package for Social Sciences version 22. Descriptive statistics were employed for univariate analysis and, independent samples t test, nonparametric tests and regression analysis for multivariate analysis.

Results

Forty-six patients met the inclusion criteria. They were all females; nine of these patients presented primarily in WGH while the remaining 37 presented secondarily for oncological treatment. Details of their demographic bio- characteristics are as shown in Figure 1 and Table 1.
Patient first contact with health care provider distribution (Figure 2) reveals that 60.9% of the sum total of patients presented primarily either at herbal or private hospital. The mean presentation time in weeks for oncological treatment (Figure 3) was longest - 89 weeks - in patients from herbal home and the tumour burden was much advanced (Figure 4) in patients from herbal home and private hospitals.
There is a significant difference in presentation time between those that presented primarily (M =11.56 Ī 5.21 weeks) and those that presented secondarily (M = 52.56 Ī 10.27weeks ) for oncological treatment: ( t = -3.56, df = 42.90, two tailed p = 0.001). There is also significant difference in tumour burden between those that presented primarily and those that presented secondarily (U = 78.5, p = 0.011).
Table 2 shows care providersí documentation of patientsí disease., None of the patients from herbal home and mission house had any documentation of their disease and only about half of patients from private hospitals had documentation. In multivariate analysis significant patientsí related factors promoting early presentation to their choice of health care provider (Table 3) are: their matrimonial setting, breast cancer awareness and mode of discovery of breast symptoms and, the significant determinant whether a breast cancer patient will have effective oncological treatment is their first healthcare provider (Table 4).

Discussion

Presentation of breast cancer patients at advanced stage is a major
contributor to increasing morbidity and mortality in the developing
countries [14, 17]. Reviews from
other developing countries (Table
5) highlight reasons for advanced stage presentation from various
nations. The variations of causes from nation to nation may be
related to their socio-cultural background [18, 19];
therefore, it is important to know the genesis of advanced stage
presentation in our environment so as to incorporate this into
future breast cancer campaign.
Outcome of this study reveals that 19.6% of the patients presented
directly in an institution where they had access to oncological
treatment while the
remaining 80.4% presented primarily at centres with limited resources
for breast cancer management with significant difference in the
disease burden
and presentation time in the two categories of patients. Though,
matrimonial setting, breast cancer awareness and mode of discovery
of breast symptoms
are prominent patientsí related factors promoting early presentation to
their primary care giver; the relative importance these factors
may be complex and interrelated. The role of matrimonial setting
in the choice of care
provider presentation may be related to family belief about breast
cancer [20], treaty with a family doctor/spiritualist,
and previous family experience of poor outcome of close relatives
with breast cancer treated at modern health facility [21].
Though, it is commonly argued that the final health related decision
rested with the patient but in African context it is a taboo for
a woman to disobey
her spouse or close relative even at the risk of her health. Therefore,
campaigns directed at early breast cancer presentation should not
only be
aimed at patients but also at her family. Breast cancer awareness
and mode of discovery of breast symptoms as determinants of care
provider presentation
reflect patient knowledge of the disease and the disease outcome
[22].
Surprisingly, breast cancer patientís level of education is not a determinant
of her early presentation to a care provider in this study (Table
3); probably academic certification may not be synonymous with awareness
of a disease and where to obtain appropriate treatment [23].
Thus literacy may not necessarily infer knowledge of a disease and this
should be considered during breast cancer sensitization drives.

†

The result of this study shows the dominant role of health care provider at
first patients’ contact as determinant of effective oncological treatment,
though being tag qualified
health
care personnel is at the prerogative of the government who is the licensing body;
unfortunately, 80.4% of the patients presented outside the setting where they
can access oncological management. The care providersí documentation of patientsí disease
in Table 2 may
be from misdiagnosis [24], lack of knowledge of the disease
and available treatment options [25]. Additionally, it may
be from poor judgement about the need for referral to the appropriate caregiver
[26, 27].
Improvement in breast cancer outcome in our society can still be accomplished
within the existing pluralist health care system through practical interventions
that are realistic and efficient [17, 21].
The goal of future research will be to find out what implementation strategies
can most effectively guide our pluralist health system reorganization to improve
breast cancer outcome. In this regard, there is need for evaluation of appropriate
certification and re -accreditation of health care institutions and their permissible
scope of enterprise on breast cancer outcome and the effect of disease recognition
training in oncology for caregivers operating herbal and convalescence homes
on breast cancer presentation. Additionally, there is urgent need for upgrading
existing government health care infrastructures and training of personnel in
oncology to cope with oncological challenges of years to come.

Conclusion

Presentation of breast cancer patients outside the setting where they can access early and effective oncological treatment seems to forms the basis of advanced stage presentation. Matrimonial setting, breast cancer awareness and mode of discovery of breast symptoms are significant patientsí bio-characteristics that determine their choice of health care provider. These factors should be considered in community breast cancer sensitization drives. Additionally, non oncologist health care providers in our pluralist health system will need re-training in oncology and their scope of enterprise should be properly defined by appropriate government institution.

What is known about this topic

Seventy to eighty percent of breast cancer patients in Nigeria present primarily at oncological centre for treatment with locally advanced or metastatic disease;

Breast cancer awareness is the determinant of early presentation to a care provider;

Determinant of effective oncological treatment is patient presentation for treatment.

What this study adds

Only about twenty percent of breast cancer patients in this study present primarily at oncological centre for treatment and about sixty percent of them presented with early breast cancer;

Breast cancer awareness, patientís matrimonial setting and mode of discovery of breast symptom are the determinants of early presentation to a care provider;

Determinant of effective oncological treatment is the care provider at first patient/care provider contact.

Competing interests

The authors declare no competing interest.

Authorsí contributions

Akinbolaji Andrew AKINKUOLIE was involved in conceptualization, design,
data acquisition, and literature search, definition of intellectual content,
statistical analysis, preparation, editing and review of the manuscript.
Amarachukwu Chiduziem ETONYEAKU participated in conceptualization, design, data
acquisition, and literature search, definition of intellectual content,
statistical analysis, preparation, editing and review of the manuscript.
Olalekan OLASEHINDE took part in conceptualization, design, data acquisition,
and literature search, definition of intellectual content, preparation,
editing and review of the manuscript. Olukayode Adeolu AROWOLO played a
part in data acquisition, and literature search, definition of intellectual
content, preparation, editing and review of the manuscript.
Rereloluwa Nicodemus BABALOLA contributed in data acquisition, and literature
search, definition of intellectual content, preparation and editing of the
manuscript. All the authors have read and approved the final version of
the manuscript.